Nurse Intervention Protocols for Scabies in Long-Term Care Facilities

Student’s Name

Institutional Affiliation
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Nurse Intervention Protocols for Scabies in Long-Term Care Facilities

Abstract

Managing scabies in long-term care institutions can be challenging. It is for this reason

that appropriate intervention protocols have to be set to guide the care nurses can offer infected

parties. This paper explores the suitability of these protocols. In doing so, gathers data from a

study involving 20 participants. Ten of these are in the control group, which is not taught the

intervention protocols the ten nurses in the study group are taught. The findings reveal that the

rate of infection in the control group is higher than is the case for the study group. Thus it is

determined that suitable nurse intervention protocols are necessary for optimizing care given to

infected parties in a long-term care facility. That said, nurses have to be taught the latest most

comprehensive intervention protocols if they are to be effective when handling a scabies

outbreak.
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Table of Contents
Abstract................................................................................................................................2

1. Introduction................................................................................................................5

1.1. Background information.....................................................................................5

1.2. Problem statement..............................................................................................6

1.3. Purpose statement...............................................................................................6

1.4. Definition of key terms.......................................................................................8

2. Literature review........................................................................................................9

2.1. About Scabies.....................................................................................................9

2.1.1. Transmission and Symptoms........................................................................10

2.1.2. Symptoms......................................................................................................11

2.1.3. Diagnosis.......................................................................................................11

2.1.4. Treatment......................................................................................................11

2.2. Scabies in long term care facilities...................................................................12

2.2.1. Challenges with controlling Scabies in Long Term Care institutions..........13

2.3. Nursing staff intervention protocols.................................................................15

2.3.1. Nursing protocols for scabies patients..........................................................16

3. Methodology............................................................................................................19

3.1. Procedure..........................................................................................................19

3.1.1. Recruiting Participants..................................................................................19

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3.1.2. Debriefing participants..................................................................................20

3.1.3. Data collection..............................................................................................21

3.1.4. Data analysis.................................................................................................21

4. Results......................................................................................................................22

5. Discussion................................................................................................................25

5.1. Importance of nursing protocols in the management of scabies......................26

5.1.1. The importance of timely response when caring for scabies patients...........26

5.2. Preventing further spread of the disease...........................................................27

5.3. Addressing the patients’ psychological wellbeing during care........................29

6. Recommendations....................................................................................................30

6.1. Educate nurses regularly on the most efficient methods of taking care of

patients 30

6.2. Documenting infected and recovered patients.................................................30

6.3. Encouraging nurses to be more decisive when handling scabies patients.......31

7. Conclusion...............................................................................................................32
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1. Introduction

1.1. Background information

Scabies is a common disease across the world, with its most significant occurrences being

in developing nations. However, it can still be prevalent in countries like the US, especially in

long-term care centers. The primary concern with the condition is its high contagiousness. In this

regard, any cases of the condition have to be treated timely to ensure patient recovery and its

control. However, prevalence mitigation is undermined by its mode of transmission, which is

through contact and sharing of contaminated clothes and beddings. For nurses, managing the

condition can be hectic especially considering that symptoms can take days to manifest. During

this period, it is easy for the sick party to infect others around them. It is for this reason that

practitioners have to find the best strategy to not only treat the condition but also counter its

spread. Further, these professionals also have to take care to not be infected lest they become

carriers too.

In developed nations like the U.S., the scabies spreads at a slower rate. However, the

trend increases in the case of care facilities, where patients are likely to come into contact with

each other more frequently. That said, such cases require nurses to be vigilant to implement the

best alternatives to minimize the spread of the disease. However, regardless of whether it is in

the open society or an institutionalized setting, these professionals are more capable of delivering

the best care if there are specific measures and procedures in place to guide patient care and

control factors that maximize spread. Notably, the condition responds well to treatment and

symptoms subside within days after administration of medication. However, there is always the

risk of reinfection if the patient is exposed to a contaminated environment. Further, since lesions
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caused by the scabies mites can be infected by bacteria, the care environment has to be

controlled as effectively as possible by the nurse to suit the patient’s recovery.

1.2. Problem statement

Long-term care institutions are susceptible to the risk of scabies outbreak. The situation is

even worse for facilities for the ageing population. For one, these parties have a weakened

immune system, which renders their bodies less capable of reacting efficiently to attacks by the

mites. Therefore, they are very likely contract the disease if they encounter these parasites.

Further, older citizens have skins that are less elastic, which makes infections on this part of the

body more serious. Itching, accompanied by the mites burrowing the skin, causes significant

damage. Further, their low immunity means that lesions and wounds from scratching can be

readily infected by other pathogens thus causing more health risks.

Since the risk of spread is higher in these institutions, outbreaks of scabies are harder to

manage. Infected parties can be quarantined and medicated to prevent further spread. However,

with the symptoms of the disease taking time to manifest, the mites can spread to more people

before the infected party can be addressed. Thus, a challenge is presented in terms of stopping

the spread of these mites. Without a proper avenue for managing patients with visible symptoms

and potentially infected parties, it is very likely that nurses can fail to contain a scabies outbreak

in such institutions.

1.3. Purpose statement

Intervention protocols provide structure to the care nurses offer to patients. As a result,

nurses can track the treatment individuals receive as well as plan for the care environment to

maximize recovery times and reduce any further spread of the disease. That said, care protocols
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associated with scabies include such initiatives as ensuring the right medication is administered,

taking care to avoid being infected by the patient, and tracking the individual’s contact history to

determine any parties at risk of infection.

This research paper provides insight into the case of scabies as is prevalent in the

American society and its care institutions as well as the protocols nurses should follow when

treating patients with the condition. An effort will be made to understand these protocols and the

impact they have on the ability of nurses to provide desired care. The importance of these

interventions will be measured in terms of the rate at which the infection spreads and the

recovery time for patients with the condition. In doing so, it will aim to answer the following

research question:

 In patients living in long-term care facilities, does the implementation of a nursing

staff intervention protocol compared to no protocol affect scabies infestation rates

within 8 weeks?

Of importance in answering this question will be a perspective observational study

conducted in a local long-term care facility in which the efficiency of 20 nurses will be evaluated

with regards to their ability to care for patients with scabies. Half of this group will be trained on

a generic intervention protocol for managing patients with scabies. The other half, which will be

the control group, will be required to offer basis care to the patients. The performances of the

two groups will be gauged according to the infection rates observed in their assigned portion of

the care facility. Further, patient’s recovery time and cases of re-infection will also be

considered. Hat said, the goal of the study would be to:

 Evaluate the importance of nurse intervention protocols on the efficiency of care

given to patients with scabies

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 Evaluate the comprehensiveness of basic care and treatment given to patients with

scabies.

For such ailments as scabies, which are contagious and difficult to diagnose early, it is

necessary to have the most effective protocols for delivering care. For nurse, these protocols not

only maximize patient outcome but they also help to control the spread of the disease.

1.4. Definition of key terms

 Scabies— a skin infection caused by skin burrowing mites living and reproducing in

the skin. The basis form of this condition manifests a linear lesions on the skin that

are itchy owing to allergic reactions to the mites and their excrements.

 Long-term care institutions— medical facilities that provide lengthy care to patients

who would otherwise be incapable of taking care of themselves or who require

special care that loved ones cannot offer

 Nurse intervention protocols— a specific set of instructions and procedures that nurse

follow when providing care to patients with a specific ailment to optimize their

recovery and prevent any escalation of the condition being treated.

 Contact history— the trail of people that have had any physical interaction with an

ailing party and are likely to be infected with whatever the patient has. These parties

may have gotten the ailment from the patient or may have been the source of the

infection.

 Rate of infection (ROI)— The number of new infection occurring in a given period.

For the case of this study, ROI = number of new infections/8weeks

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2. Literature review

2.1. Theoretical frameworks: Roy’s Adaptation Model

The choice to consider the importance of intervention protocols was inspired by Sister

Callista Roy’s Adaptation model. According to this model, a person is a biopsycholsocial being

who continuously interacts with constantly dynamic environment (Ursavaş et al., 2014).

Therefore, the goal of nursing is to promote compliance and life expectancy on the patient’s side

by helping them attain a more sustainable balance with the environment (Salviano et al., 2016).

In doing so, the functions of the practitioner shift from being service based to being patient based

(Ibid). However, since the environment is always changing, it is impossible to attain an optimal

balance. Therefore, a person has to adapt to external stimuli constantly (Jennings, 2017).

Notably, the theory utilizes four primary domains: person, environment, health, and nursing. The

person, as was observed earlier, is a biopsycholsocial that has to adapt to an ever-changing

environment (Ursavaş et al., 2014). On the other hand, the environment refers to external stimuli

that draw specific reactions from the person. These stimuli can be focal stimuli that affect the

person directly and require immediate attention; contextual stimuli, which accompany the focal

stimuli and affect the situation they cause; and residual stimuli, whose effects are difficult to

determine. The third domain, health, refers to a position in which the patient can adapt to stimuli

with as much efficiency as possible. Lastly, the nurse is the caregiver whose role is to help the

person adapt to stimuli.

Of importance to this paper is the nurse domain, which captures the duties of

practitioners towards improving the patient’s ability to achieve good health. Whereby, health is

the ability to continually react and adapt to stimuli. In this regard, Roy specifies six steps a nurse

should take to maximize the patient’s ability to adapt to stimuli. These steps are:
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i. Assess the patient’s behavior as they react to specific stimuli

ii. Assess the stimuli that is causing the patient’s reaction

iii. Diagnose the nature of the stimuli and the impact it has on the patient

iv. Set a goal that will be achieved after intervention

v. Implement the intervention that will improve the patient’s ability to adapt to the

said stimuli

vi. Appraise the intervention based on its effectiveness in attaining the goal set

beforehand.

For nurses to be effective in providing care, it is necessary to have a structure that guides

their actions, in addition to ensuring there are specific outcomes being sought. Nursing

intervention protocols are as effective as their ability to be comprehensive. Roy’s six-step

process provides a suitable guideline for nursing intervention protocols. Not only does it cover

six important aspects of providing medical care, but it also provides enough flexibility with in

each step to ensure its application in any given setting is possible. It was sought as the primary

guideline for the interventions proposed for this particular project.

Not only would the nurse be responsible for offering care to patients, they would also be

required to make important diagnostic decisions that would maximize the efficiency with which

care would be given. If compared to the four dimensions proposed by Roy, the patients would be

the first dimension, scabies would be the stimuli emanating from the environment, health would

be the ability of the patients to respond to treatment, and the nurses will be tasked with providing

care to infected parties and preventing the healthy patients from being exposed to the stimuli.

In this regard, the six-step process will comprise of the following efforts by the nurses,

which are organized with respect to the order in which they were presented earlier.
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Step 1: Assessing patient behavior

The nurse would be required to keep an eye on the patients to identify any signs of

scabies. Doing so would mean making constant rounds and observing the residents as frequently

as possible. Further, the nurses will have to trace the contact history of any affected parties to

determine the nature of their interaction with the patients and chose whether they needed to be

tested for the mites.

Step 3: Assessing the Stimuli

Here, the nurses will be tasked with verifying all the cases that attracted attention.

Notably, there are conditions that may show similar symptoms as scabies. Therefore, the nurses

will have to use their knowledge of the condition to determine which one needs attention. Any

instances of skin infection would have to be reported for further analysis. However, the nurses

are required to pay specific attention to the patients that show signs of scabies.

Step 4: Diagnosing

This step would require three primary methods of testing: microscopy, dermatoscopy,

and professional judgment by the nurses. Notably, the first two may fail to give conclusive

results (Jung et al., 2018), which would then require the nurses to utilize the training and

awareness they have regarding scabies to offer make decisions on whether patients are infected

with the condition.

Step 4: Setting goals

The goals for intervention were set before the project was initiated. However, at the

individual level, it is expected that the nurses will:

- Aim to diagnose the patients as soon as possible

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- Identify any instances of resistance to treatment to ensure more effective measures are

given to the affected parties

- Ensure that no healed patients are reinfected

- Minimize the infection rate

- Reduce instances where patients experience psychological and emotional stress

during treatment.

Step 5: Intervention

The nurses will have to perform the following duties to attain the goals listed above:

a. Immediate isolation of the patient

Any patient that shows signs of the disease should be isolated as soon as possible. This

can be done by either placing the subject in a specialized area of the facility or simply restricting

their movement and interactions with other parties. In the case of patients with dementia or any

condition that may cause them to wonder off, the nurse may be required to take drastic measures

such as locking the patient in an isolated room. However, this move might distress these parties

albeit for their own good.

b. Administering treatment

The isolated party can be treated using either topical or oral agents. Topical agents are

typically applied generously from the neck down. The choice of the scabicide may differ from

one institution to the other. However, some common ones include permethrin and ivermectin. In

the case of crusted scabies, the practitioner may use topical keratolytics like salicylic acid, which

would be applied concurrently with scabicides but not at the same time. However, Ong et al.

(2019) observes that there have been cases of growing resistance to these topical drugs. Thus,
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practitioners are evaluating the possibility of using mexidectin as an oral agent in the treatment

of the condition.

c. Disinfecting the environment

While scabies does not spread easily through clothes and beddings, it is still necessary to

disinfect the patient’s environment. Doing so helps to prevent cases of reinfection. Disinfection

includes washing the patient’s garments and beddings in hot water. The water has to be above 75

°C since the scabies mites are extremely intolerant to hot temperatures. Any items that can not be

subjected to this treatment should be sealed in air-tight bags and left for 72 hours, which it the

longest the mites can survive without a host. The room and its furniture should also be

disinfected after the patient has been treated. Ong et al. (2019) suggest using chaloramine 5% to

treat the room. Further, the nurses should avoid any direct physical contact with the patient to

avoid being infected themselves. This caution should be extended to the patient’s garments and

personal belongings that might possibly be contaminated.

d. Managing other complications caused by scabies

Scabies cause lesions on the skin, which may persist after treatment. Further, patients

may injure themselves when they itch following the irritation caused by the mites. These

openings can be active sites for bacteria and other disease causing microorganisms. That said, the

nurse should keep track of recovered patients to ensure that they do not contract secondary

infections through these openings on the skin.

Furthermore, a patient that has been treated is not immune to reinfection. Since there is

always the possibility that the mites might still be around, especially after being harbored by

other patients not showing symptoms of the condition, it is necessary for nurses to pay attention
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to the recovered subjects. Care should be taken to avoid reinfection, which might cause the

patient more problems.

Step 6: Appraise interventions based on the goals set

At this level, the nurses will have to keep track of the patients and record the number of

new infections as well as reinfected parties at the end of the week. These numbers will be used to

assess the efficiency of the care provided to the patients.

Overall, there were no shortcomings of Roy’s adaptation model as was used in this

project. Not only did it offer guidance in terms of providing suitable intervention protocol, but is

also offered significant freedom in terms of its application to tis specific case.

2.2. About Scabies

Scabies is a skin infestation that can be very irritable for affected parties. A small mite

called Sarcoptes scabier var homonis, shown in Figure 1, causes it. A single infestation can be

caused by only 10 to 25 mites but can be very troublesome for the affected party. Despite the

female mite laying many eggs, only a few survive. Most of the eggs are disposed by mechanical

action such as scratching and bathing while the rest are killed by the host’s natural immune

system. Infection occurs when female mites burrow into the skin. There, they feed on skin cells

and lay eggs. Irritation occurs because of the allergic reaction to the mite’s and their excrement

beneath the skin. However, it should be noted that occurrence of these mites does not indicate

poor hygiene. In fact, there are no preferable victims since the mites can infect anyone who

encounters them. However, care facilities tend to be at a higher risk following congestion and
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unhindered interactions between residents. Failure to treat the condition can lead to an outbreak,

which in turn can usher in other conditions resulting from infection of scratch wounds.

In some serious cases, scabies can advance to a form called ‘crusted scabies’ or

‘Norwegian scabies’. This form of the infection occurs in patients with low immunity. The result

is that the parasite forms colonies on the skin where millions of mites are present. The infection

appears as hyperkeratotic, fissured plaques, and nodules on the patient’s skin (Jaramillo-Ayerbe

& Berrío-Muñoz, 1998). This severe form of scabies causes more than irritation and the host can

feel severe pain, in addition to being incapable of performing their daily duties such as walking.

However, treatment is relatively simpler with the symptoms clearing up within weeks of

appropriate treatment. This sever form of scabies is rare.

2.2.1. Transmission and Symptoms

The primary mode of transmission is through direct skin contact. However, in less

common cases, the mites can spread through contaminated garments, beddings, and personal

linens. The latter case is less probable because of the parasite’s short lifespan without the host.

The mites can survive up to 36 hours without a human host at room temperature (McCarthy et

al., 2003). The mites trace their hosts using both smell and thermal senses. After finding a host,

they burrow into the skin and start reproducing within 30 minutes (McCarthy et al., 2003).

Infestation rate in the host increases in the first month and will start to fall in about three months

following the host’s immune response to them. Parasite burden reaches up to 25 females per

person in about 50 days although the average count per person is around 10-12 mites (McCarthy

et al., 2003).

Notably, spread through beddings and clothing is less effective than skin to skin contact.

In a study by Mellanby, K. (1944) revealed that only four participants out of 272 attempts
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contracted the mites after sleeping in beds previously occupied by infected parties. However, the

situation is different for patients with crusted scabies. These parties’ immediate environment is

heavily infested, making parties around them more susceptible of contracting the ailment

(Karthikeyan. 2009). That said, it is very easy to get scabies from the beddings and clothes of

patients with crusted scabies. In fact, these parties are very capable of causing a scabies epidemic

(Ibid).

2.2.2. Symptoms

After infection, the symptoms start to show after three to six weeks. Aside from the

irritation they cause, the mites can be identified as linear lesions appearing under the skin in

which are the parasites, their eggs, and excrements. The lesions can develop into boils if infected

by bacteria. Further, the bacterial infection can occur from skin raptures caused by scratching. As

for crusted scabies, symptoms include hyperkeratotic, fissured plaques, and nodules on the

patient’s skin.

2.2.3. Diagnosis

A dermatologist can easily identify signs of scabies. However, a more reliable means of

diagnosing the condition includes microscopic evaluation of skin samples around the lesions on

the infected party’s skin. The mites are easy to identify under a microscope. On the other hand,

the symptoms of crusted scabies are easy to identify on the patient’s skin. However, same as the

regular form of the condition, a microscopic evaluation of skin samples around the infected

areas.
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2.2.4. Treatment

Topical agents like permethrin and lindane can be subscribed to patients. The former of

the two causes prolonged polarization of nerve membranes among arthropods (Shimose &

Munoz-Prince, 2013). On the other hand, lindane cause neural hyperstimulation, which paralyses

the parasites (Shimose & Munoz-Prince, 2013). The doctor can also prescribe ivenectin to

patients. After commencing medication, symptoms will start to recede in days and, within weeks,

for severe cases like crusted scabies, the patient will be healed.

2.3. Scabies in long term care facilities

Scabies is not selective of the parties to infect. That said, anyone can contract the skin

condition regardless of their gender, age, or race. However, certain risk factors increase the

likelihood of there being an outbreak of the condition. Among them is living in crowded areas or

situations where one encounters many people. In such scenarios, any occurrence of the condition

will spread fast, thereby making it harder to manage it. Long-term care facilities provide such

environments and are among the few places in developed countries like the U.S. where the

condition can spread quickly. This observation is especially true in nursing homes for the elderly,

who are susceptible to many conditions including some that affect the skin. The situation is made

worse by the fact that scabies does not always manifest in the same fashion for all parties. In fact,

not all people may have an allergic reaction to the mites; hence, some people may not feel itchy

after infection.

In a study conducted in the U.K. by Cassell et al. (2018), it was observed that the

condition could manifest differently from the fashion with which clinicians are familiar,

especially among the elderly. The study, which involved 230 elderly residents, showed that 51%

of those diagnosed with the condition were asymptomatic (Ibid). In such cases, it may be harder
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for the nurse and other medical practitioners to diagnose the patients correctly without using

microscopy and dermatoscopy. However, the same study also observed that these methods of

diagnosing the condition are not effective for the elderly (Ibid). Therefore, it is challenging to

make the right diagnosis for this population, which increases efficiency with which patients can

be identified and treated. Because of these challenges, it is easy for practitioners to misdiagnose

their patients. The result is that the condition gets to spread to unsuspecting parties until the error

can be noted. Rectifying the mistake is often costly, as was observed in the case reported by

Murakonda et al. (2004). Furthermore, such cases of misdiagnosis can embarrass the facility,

especially considering that even the nurses will be open to infection because of their

unawareness (Ibid).

2.3.1. Challenges with controlling Scabies in Long Term Care institutions

As was aforementioned, managing scabies in long-term care facilities, especially nursing

homes is quite difficult. These challenges associate with various factors that affect not only

diagnosis but also treating the condition. Without addressing these issues, it would be harder for

nurses to attain optimal recovery and control of cases of scabies. That said, the following are

primary barriers to effective care:

a. Undermining the seriousness of the illness

Since the condition is not fatal, it is common for people to undermine its significance.

According to the WHO, the condition only led to 0.21% of disability adjusted lifestyle.

Therefore, despite more than 200 million people being infected with the condition

simultaneously across globally, the disease does not draw much attention as health risk.

However, undermining may be risky considering that it has the potential to lead to other

conditions such as septicemia and chronic kidney disease because of the bacterial infection that
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can complicate it. It is for this reason that the WHO classified the disease, among other

ectoparasites, as Neglected Tropical Diseases.

b. Lengthy incubation period

The symptoms of scabies take three to four weeks to show, it is difficult to detect the

condition early. During this time, the infected parties can still spread the mites to others around

them. As a result, the probability that other people, including the practitioner have been infected

before nurses can detect the condition among patients, is quite high. Scabies can spread even

further before everyone infected can start showing symptoms. During this time, parties that have

already healed can be re-infected during.

c. Low parasite burden

The average parasite burden per person for scabies is up to 25 females. While this low

count reduces the acuteness of the condition, it can make it harder to use microscopy and

dermatoscopy to diagnose the condition, especially among the elderly. Further, most of the eggs

are eliminated when through mechanical actions such as scratching and bathing. This low

number of parasites reduces the sensitivity of some common diagnostic techniques like

microscopy and PCR diagnostic (Walton & Currie, 2007). On the other hand, dermatoscopy are

highly sensitive as long as an experienced dermatologist is sought and diagnosing may require

expensive equipment (Walter et al., 2011). These challenges with diagnosing the condition may

confuse caregivers, especially considering that the ailment shares some similarities with other

common skin conditions. Instances of misdiagnosis end up being costly for the long-term care

facilities as they pave the way for outbreaks in the wake of untimely detection and treatment of

the condition (de Beer et al. 2006).

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2.3.1. Gaps in Research on Nursing Staff Intervention Protocols for Scabies in Long-

Term Care Facilities

As has been aforementioned, scabies is highly contagious. Therefore, while basis

interventions can help to curb cases of scabies, an outbreak in a long-term care facility would

require more effort if the institution is to deal with the problem effectively. This observation is

especially true for nursing homes since the elderly have a weaker immune system. Coupled with

other factors such as the lengthy incubation periods, which make it harder to diagnose the

disease, the challenge of providing care to such patients is higher. That said, it is necessary to

have a plan that caters for all the risks associated with the condition in such settings. Such plans

can ensure the caregiver can cover all the necessary factors that increase infection rates in such

institutions.

Currently, there are extensive works on how to deal with scabies in long-term care

institutions. Most of them cover the interventions mentioned in the previous section of the paper

with some going as far as providing specific interventions for parties with crusted scabies. In

these sources, the scholars explore the importance of tracing contact history, isolating affected

patients, treating all parties suspected of being infected and using more than one method of

diagnosing the condition. However, only a select few address the emotional strain that can be

caused by isolating the patient. When considering the case of long-term care, especially for

patients with conditions requiring special care, such as individuals recovering from stroke, it is

necessary to emphasize maintain the patient’s emotional wellbeing. According to Lamers et al.

(2012), emotional wellbeing is favorable for promoting faster recovery and survival rates for

patients with serious conditions. Even when leaning towards less life threatening scenarios,
NURSE INTERVENTION PROTOCOLS FOR SCABIES
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emotional wellbeing still plays an important role in the health of patients in long-term care

facilities.

D’Acquisto (2017) observes that there is a direct relationship between emotional wellness

and immune response. The research reveals that emotional wellness improves immune response

emotional disturbances can reduces immune response. When applied to the case of scabies,

where individuals with weaker immunity are more susceptible, stressed patients are likely to

contract or react more adversely to the condition. Therefore, while nurse may offer suitable

medical interventions, failing to ensure the patients are not stressed can increase chances of

reinfection. This observation is especially true if the individual’s belongings and surroundings

have not been disinfected. Since it takes weeks for scabies to heal, isolation across this period

can cause emotional stress on the patient (Abad, Fearday & Safdar, 2010. The fact that most

scholars do not note the danger that this isolation can cause on the patient’s wellbeing signifies a

significant lack of consideration for the role of the nurse in promoting emotional wellbeing of

patients receiving care for scabies.

Covering this gap in knowledge would help to push for the recognition of the role of the

nurse in promoting emotional wellness among patients with scabies. Isolation is an integral part

of care, but the emotional stress it can cause can undermine the goal to optimize patient recovery.

That said, intervention protocols for scabies should include some aspect of emotional

intelligence on the nurse’s part.

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3. Methodology

 Overview of approach design

The study took place in a local nursing home where there had been an outbreak of

scabies. Considering that actual patients were involved in the study, it was mandatory that the

nurses know of the primary care for the condition. That said, the patients were not placed in any

unnecessary risk. The study also involved the head nurse who would oversee the performance of

these nurses to ensure the institution’s demands for quality of care were not undermined during

this study.

 Participant information

All nurses had to have had at least 12 months of practice in nursing. Further, each had to

have some knowledge of scabies and the basic treatment it required. No age limit was set and all

nurses were free to apply to be part of the study. The study was conducted in a local nursing

home where there had been cases of scabies reported.

 Methods

The study involved training nurses on a custom made intervention protocol for scabies.

The study group was trained for two days before the study while the control group relied on the

participant’s knowledge of interventions for the condition. The nurses would collect data on

infection rates (x) and the number of patients with the condition (n),.

 Instruments— At the beginning of the study, a questionnaire was used to gauge the

nurses’ knowledge of the disease and ability to care for patients with it.

 Data collection

Each nurse was responsible for reporting to the head nurse about new infection cases (x)

and the number of sick patients (n). This data was recorded on a weekly basis in the table below:
NURSE INTERVENTION PROTOCOLS FOR SCABIES
23

Week Number Number Cumulative Cases of Number

of of new number of reinfection of
patients infections infections infected
with (x) (∑x) staff
Scabies
(n)
Start n0= 0 0 0 0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8

 Data analysis plan

The data will be analyzed to determine the infection rates in the two groups. Infection

rate will be calculated using the formula:

x8/8.

Where x8 = ∑x

In addition, the number of healed parties will be determined using the following formula:

Number of healed patients= ni-ni-1-xi

Where ni is the number of patients with scabies in a given week, xi is the number of

infections in that week, and ni-1 is the number of patients with scabies in the previous week.
NURSE INTERVENTION PROTOCOLS FOR SCABIES
24

4. Procedure

 Standard measures in both cases: Patients would be given a single application of

permethrin 5% unless stated otherwise by the physician.

4.1. Recruiting Participants

Permission was sought from the institution’s management and a memo on the research

opportunity was posted to all nursing staff. All interested parties were allowed to submit their

application through an email indicated in the memo. One week after the deadline for application,

the nurses were asked to meet in a local community hall. The attendants would then be vetted

according to the experience they had with the disease. Afterwards, the qualified participants

would be divided into two groups, the control group and the study group. These individuals

would then fill in an informed consent slip and then assigned a specific identification index

4.2. Debriefing participants

A meeting was held before the study. All the participants were asked to fill in a

questionnaire to gauge their knowledge of the disease and the suitable methods for caring for the

patients. The participants were then screened for any infection that would place them and the

patients at risk. Afterwards, they would be informed on their individual duties during the study.

A power point presentation was used to perform this task. The basic requirements for both

groups were:

 The nurses had to maintain hygiene in the care environment, which included keeping

acceptable levels of personal cleanliness. All participants had to use the equipment

provided by the institution to help achieve this goal. Among them were disinfectants

and protective clothing.

NURSE INTERVENTION PROTOCOLS FOR SCABIES
25

 The nurses had to implement the most effective care possible for the participants.

 The nurses had to protect themselves from infection.

 The nurses had to report any new cases of infection to the institution’s nurse leader.

 The nurses had the freedom to use their technical skill to maximize the efficiency of

the care environment.

After the joint debriefing, the study group was briefed separately on the additional

training they would receive. For two days after the meeting, the group was trained on a custom

intervention protocol for scabies. A PowerPoint presentation was used to deliver this training

alongside an instructional manual to which they could refer. The training included details on:

 Preventing infection of new parties

 Identifying symptoms of scabies before a definitive test was performed

 Disinfecting clothes and beddings of infected parties

 Isolating infected parties

 Controlling interactions with the infected patients to ensure they are not

psychologically or emotionally strained during the isolation all the while ensuring any

parties that interact with them are not at risk.

 Tracing the contact history of infected residents and submitting parties of interest for

cautionary treatment.

4.3. Data collection

Each participant had to report the infection cases and the total number of patients with the

condition per day. The information for each group was recorded in a tabular forms kept by the

head nurse, who then forwarded it to the researcher at the end of each week.
NURSE INTERVENTION PROTOCOLS FOR SCABIES
26

5. Results

Thirty nurses applied for the research. Twenty of them were eligible to take part in the

study. The youngest participant was 25 years old while the oldest was 35. Twenty nurses took

part in the study. Of these, fourteen were female and the rest male practitioners. The youngest of

the participants was 25 years old while the oldest was 35 years. It was decided that the eligible

parties be divided into two equal groups of ten practitioners each. The control group had four

male nurses and six female ones. The study group had two male nurses and eight female ones. Of

the twenty participants, seventeen had taken care of patients with scabies before while three had

only witnessed patients receiving care. Further, six participants had received earlier training on

taking care of patients with the condition. All nurses could identify the symptoms of scabies and

knew about the primary care necessary for infected patients. None expressed any concerns about

taking care of patients with scabies.

The study started with n=37 patients for the study group and n=35 for the control group.

The most number of infections were reported on the fourth week, (x=3) for the study group and

(x=7) for the control group. The cases of infection declined for the study group, with the last one

being reported in the fourth week (x=1). However, the cases of infection in the control group

remained significant with two cases being reported in the eight week. By the end of the research,

there were seven patients with scabies in the control group while only one remained in the study

group. Eight of the patients reported increased skin irritation in the first week after using

permethrin 5%. In the first week after receiving their dose of the medication, the patients still had
NURSE INTERVENTION PROTOCOLS FOR SCABIES
27

lesions on their skin. Afterwards, their skin cleared in the second week. Most of the patients had

healed in the third, fourth and fifth weeks. The party that took longest to heal was in the study

group. One of the patients in the third week had a weak immune system and despite the initial

intervention, remained infected in the eight week. Caution was drawn to this patient as the doctor

emphasized extra care, including a single dose of oral ivermectin was administered on the second

week of care. Extra caution was taken to ensure the patient’s condition did not advance into to

crusted scabies. However, by the time the study was being completed, the patient was showing

signs of improvement and most of the rash had subsided.

In all cases, infected parties were isolated to prevent further spread of the disease. Three

nine patients with dementia had to be locked in to prevent them from wondering off. Of these,

five were under the study group while four were in the control group. By the end of the study,

five patients, all under the care of the control group, reported psychological frustration and stress

from being isolated and lonely. Therefore, while the nurses had ensured these patients recovered

from scabies, not much was done to guarantee they were not lonely during the minimal three

weeks of care each patient received. The results of the study are represented in Table 1 and Table

2.
NURSE INTERVENTION PROTOCOLS FOR SCABIES
28

6. Discussion

Despite being very contagious, scabies responds well to treatment. That said, Permethrin

5% yielded good results. In fact, most studies indicate that that the drug is not only effective but

it is also friendly to both the caregiver and the patient. Ranjkesh et al. (2013) observes that the

medication does not stain clothes, does not have an unpleasant smell, and is easy to apply.

However, some people may react to it, as was seen in the study. In these instances, these parties

felt some skin irritation as was seen in the case of the study, where eight patients, three in the

study group and four in the control group, proved to be mildly allergic to the medication.

However, despite its efficiency, some people may find the medication ineffective. Khalil

et al. (2017) observe that the cases of resistance to permethrin are increasing. This trend is

concerning considering that the diseases is quite prevalent in society, and even more in long-term

care facilities. The authors identify several factors that cause resistance to the drug. The

following were most significant to this study:

- Incorrect diagnosis, which reduces the accuracy of the prescription offered.

- Non-compliance to the prescription

- Local reaction to the drug, which reduces the efficiency of the medication

- Mutation of the scabies mites

From the study, only one patient showed signs of resistance to the medication. The

patient had to take two doses of permethrin. The first dose was administered immediately after
NURSE INTERVENTION PROTOCOLS FOR SCABIES
29

diagnosis. However, as the symptoms persisted, a second dose of permethrin 5%was

administered alongside oral ivermectin, which is the most suitable dosage for crusted scabies, in

the second week of treatment (Rosumeck, Nast & Drassler, 2018). According to the primary

physician, the patient had been diagnosed with a weakened immune system. Therefore, without

further intervention, the patient’s condition would have advanced into crusted scabies. The

second dosage was administered as would be the case for a patient already diagnosed with

crusted scabies. That said, of the three factors associated with resistance to permethrin, it was

concluded that local reaction was the most likely cause of the resistance the patient showed to the

initial prescription.

6.1. Importance of nursing protocols in the management of scabies

Nursing intervention protocols offer practitioners the necessary guidelines to not only

achieve maximize the patient’s recovery time but also to avoid other risks a patient may face. In

the case of scabies, these interventions are effective if they address three primary concerns.

These are:

- Providing timely care regardless of the visibility of symptoms

- Preventing further spread of the disease

- Catering to the psychological and emotional wellbeing of the patients in the wake of

being isolated minimize spreading

6.1.1. The importance of timely response when caring for scabies patients

The most important step in taking care of patients with the disease is identifying any

infected parties. That said, one can rely on professional means, which include dermatoscopy and

microscopy. However, as was noted by Cassel et al. (2018), these two may not always work.
NURSE INTERVENTION PROTOCOLS FOR SCABIES
30

Therefore, caregivers should have the awareness to identify anybody everybody that might be

infected. Doing so may involve tracing the contact history of the given patient as was done by

the study group. Further, the practitioners should notice the symptoms of infected parties and

administer treatment for the slightest evidence of the disease (Lay et al., 2011). Any suspected

incidences of the condition should be treated to cater for patients in the incubation stage of the

condition (FitzGerald et al. 2014).

Timely treatment also ensures that infected parties do not get to infect others before their

symptoms manifest. Ideally, individuals in the incubation period may not manifest the condition

but can still infect others (FitzGerald et al. 2014). When comparing the infection rates in the two

groups of nurses, it was noted that more patients were infected when nurses did not have the

skills to identify infected parties and trace the contact path. Ideally, these skills were taught to the

study group during the two-day training period. As a result, the rate of infection in the study

group was significantly lower than was the case for the control group. While the nurses in the

latter group did have the awareness to identify symptoms of the condition, they were less aware

of the importance of placing parties in the contact history under care. That said, while patients

reacted well to treatment, the infection rates stayed high across the four weeks. Without training,

the nurses were only effective in offering primary care but were less efficient in predicting cases

of infection and preventing any further spread among the healthy population. However, for the

first two, it may be argued that the high infection rates were because of patients infected earlier

having passed the incubation period for the scabies. That said, the CDC specifies that it takes

approximately 2-6 weeks for the symptoms to manifest.

NURSE INTERVENTION PROTOCOLS FOR SCABIES
31

6.2. Preventing further spread of the disease

Since everyone exposed to the patients, their clothing, and beddings is at risk of being

infected, it is necessary to have measures in place that mitigate the contagiousness of the scabies.

That said, three levels of preventive care have to be implemented. First, the nurse has to have

protective gear when attending to the patient (Makigami et al., 2009). While scabies is

contagious, its ability to infect is limited to the amount of contact one has with the patient.

Therefore, if one uses protective clothing, the likelihood of contracting the parasites is low

(Bouvresse & Chosidow, 2010). This observation is verifiable from the study, where no cases of

nursing staff being infected were reported.

The second level of prevention applies to all healthy parties exposed to the condition. In a

long-term care facility, it is harder to control the number of people encountering the patient.

However, not everyone who interacts with the infected party will get the condition. Regardless, it

is advisable to avoid any form of unsupervised interaction with the individuals (Sarwar, 2015).

That said, the infected parties or anyone suspected to be infected has to be isolated. Parties

susceptible to wondering, such as those suffering from dementia have to be locked in their rooms

until they are healed. Alternatively, the can be kept under close supervision at all times, which is

a more demanding initiative. Failure to implement a suitable plan for preventing other residents

from being infected will lead to a higher infection rate. This trend was observable in the control

group, where, without effective measures, the rate of infection was higher. Across the eight

weeks, ROI for the control group was 4.5 and 1.125 for the study group.

The third level of prevention applies to the parties that have already recovered. Unlike

first time patients, the incubation period for reinfected parties is shorter. A higher rate of

reinfection means more time would be needed to clear a scabies outbreak. Further, the
NURSE INTERVENTION PROTOCOLS FOR SCABIES
32

effectiveness of the caregivers is placed into question when there are higher rates of reinfection

(Chosidow, 2006). This observation is especially true if the mode of reinfection was through

contaminated personal items belonging to the client. However, since the incubation period for

reinfected parties is shorter, timely care is easier to give. That said, the caregivers should insist

that the patients’ personal belongings and room of residence be disinfected alongside giving the

patient the desired treatment for scabies. Further, the nurse should supervise the interactions of

all patients to ensure the recovered parties are not infected again. That said, without proper

caution, the rate of reinfection increases. In this regard, the control group in the study had seven

cases of reinfection, while no case was reported for the study group.

6.3. Addressing the patients’ psychological and emotional wellbeing during

care

Isolated patients are likely to become emotionally distraught. This observation is

especially true for individuals denied any form of interaction with other people other than their

caregivers (Barratt, Shaban & Moyle, 2011). In the given study, most patients took three weeks

to heal, which meant they had to be isolated for all this time. It is in such instances that nurses

can take the initiative to ensure these parties do not feel too lonely. That said, the nurses should

be taught to be compassionate and to engage the patients (Guilley-Lerondeau et al., 2017). Doing

offers the sick the mental stimulation, which can improves their psychological wellbeing in the

wake of being in isolation.

Notably, psychological wellbeing plays an important role in improving recovery times for

patients (Abad, Fearday & Safdar, 2010). Since individual immunity levels also affect recovery

times for patients with scabies, it is necessary to ensure each one is at prime physical condition.

In this regard, the psychological state of these parties should not be ignored. From the study, it
NURSE INTERVENTION PROTOCOLS FOR SCABIES
33

was identified that the nurses in the control group were not equipped to offer patients the mental

stimulation they required. However, there was not much information or time to study the

association between psychological wellbeing and recovery times for the patients. That said, five

patients in the control group reported mental strain, which indicated these practitioner’ lack of

awareness for the need to protect the patient’s psychological wellbeing. No cases were reported

for the study group.

7. Recommendations

Providing the best care for patients depends on the nurses’ knowledge of the given

condition. In the case of scabies, this knowledge is important as it not only ensures patients

recover, but it also reduces its spread to healthy residents in long-term care institutions. Offering

the best training ensures that all nurses can adhere to acceptable standards of care in every

instance, which maximizes the efficiency with which every aspect of care is addressed. However,

the intervention protocol has to be comprehensive if it is to minimize spread. That said, the

following recommendations should be considered in every care instance:

7.1. Educate nurses regularly on the most efficient methods of taking care

of patients

Nursing interventions protocols have to be evidence-based. With the emergence of every

new measure to improve efficiency of care, these protocols have to be changed to suit the most

optimal method in practice (Wong et al., 2015). That said, if the pathogens develop any

resistance to medication, the interventions should change to suit these measures. For scabies,

these advancements can mean new methods of identifying parties potentially infected with

scabies. One such measure includes relying on more than one measure to detect patients infected
NURSE INTERVENTION PROTOCOLS FOR SCABIES
34

with the condition. If microscopy and dermatoscopy are not sensitive enough, the nurse should

use their awareness of the symptoms and contact history to determine patients that need to be

subjected to care. In addition, taking care of the patients’ emotional and psychological wellbeing

is important as studies show a direct relationship between stress and low immunity levels

(D’Acquisto, 2017).

7.2. Documenting infected and recovered patients

Keeping records makes it easier to track patients’ progress. In the case of scabies, these

records can be kept with regards to the number of people infected and those that have recovered.

Such information makes it easier for the institution to plan for resources and to determine the

best interventions for any abnormal cases. Recovery time can be used to identify patients with a

lower immunity, thus paving way for the administration of better prescriptions. Doing so can

help to avoid any instances of crusted scabies, which would pose more risk to the initiatives

taken to eradicate any outbreak of scabies in a long-term care institution. Further, data collected

can be used to determine the effectiveness of the protocols implemented (Chuang, Howley, &

Lin, 2015). As a result, any positive outcomes can reinforce efficient measures while negative

scores can be used to push for further research to identify better methods.

7.3. Encouraging nurses to be more decisive when handling scabies patients

Screening patients for scabies would not bear the best results in all the cases. Therefore, it

is likely that patients, including those in mite’s incubation period, might not receive timely care.

However, the nurses are in the best position to identify any residents with scabies in a long-term

care institution (Gould, 2010). After training, the institutions should have faith in the skill of

their nurses. That said, the nurses should be encouraged to use their intuition and awareness of
NURSE INTERVENTION PROTOCOLS FOR SCABIES
35

contagiousness of scabies to make the decision on residents that should receive care. Similarly,

they should be able to identify patients that have healed and those that are resistant to

medication. In these instance, the practitioners should make timely decisions that will encourage

the institution and its physicians to take the right course of action to optimize the results from the

interventions.

8. Conclusion

Despite being easy to treat, scabies should not be overlooked by caregivers and doctors.

The disease offers enough platform for secondary infections, which may be more dangerous for

the customer. It is for this reason that every case of scabies should be handled with urgency and

caution. This observation is especially true for long-term care institutions, which offer a suitable

environment for the condition to spread. Urgency ensures the disease can be dealt with and

eliminated as soon as possible. Caution, on the other hand helps to minimize infection rates.

Failure to prevent the spread of the disease will only result in more patients being infected. As a

result, the costs of care will increase for the subject institution.

Nurse intervention protocols for scabies aim to facilitate both urgency and caution during

care. Not only are nurses directed on how to take care or patients, but they are also taught to

identify any parties at risk and to ensure the care environment facilitates optimal recovery for the

patient. Ideally, a suitable protocol is one that is comprehensive enough to cover every aspect of

care while providing enough details to ensue enough caution is observed in every instance of

care.
NURSE INTERVENTION PROTOCOLS FOR SCABIES
36

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NURSE INTERVENTION PROTOCOLS FOR SCABIES
40

Appendix A: The scabies mite as seen under a microscope

Figure 1. A female mite full of egg as seen in X 100 magnification (Steen et al., 2004).
NURSE INTERVENTION PROTOCOLS FOR SCABIES
41

Appendix B: Results from the Study

Table 1. Data for the control group

Week Number Number Cumulative Cases of Number

of of new number of reinfection of
patients infections infections patients
with (x) healed
Scabies
(n)
Start n0= 35 0 0 0 0
Week 1 38 3 3 0 0
Week 2 43 5 8 0 0
Week 3 27 4 12 0 20
Week 4 17 7 19 1 7
Week 5 13 5 24 3 9
Week 6 14 6 30 2 5
Week 7 12 4 34 0 6
Week 8 7 2 36 1 7
If rate of infection = number of new infection/8 weeks

ROI for control group= 4.5

Total number of reinfected parties= 7

Table 2: Study group

Week Number Number Cumulative Cases of Number

of of new number of reinfection of
patients infections infections patients
with (x) healed
Scabies
(n)
Start n0=37 0 0 0 0
Week 1 38 1 1 0 0
NURSE INTERVENTION PROTOCOLS FOR SCABIES
42

Week 2 40 2 3 0 0
Week 3 23 2 5 0 19
Week 4 16 3 8 0 8
Week 5 10 1 9 0 7
Week 6 5 0 9 0 5
Week 7 2 0 9 0 3
Week 8 1 0 9 0 1
If rate of infection = number of new infection/8 weeks

ROI for study group= 1.125

Total number of reinfected patients=0

NURSE INTERVENTION PROTOCOLS FOR SCABIES
43

Appendix C: Questionnaire issued to All Nurses before the Study

1. How old are you?

2. How long have you been a nurse?

3. Have you ever encountered a case of scabies during your career? How many times

have you done so? When was that?

4. Have you witnessed a patient receiving care for scabies?

5. Have you taken care of a patient with scabies?

6. Have you or anyone close to you ever had scabies?

7. Do you know the primary care a patient requires when they are diagnosed with

scabies?

8. What are the interventions required for a patient with scabies?

9. Do you know how to identify the symptoms of scabies?

10. What are the primary symptoms associated with scabies?

11. What do you feel were the major challenges associated with caring for such patients?

12. What concerns do you have about taking care of patients with scabies?

13. Have you had any training on caring for patients with scabies?
NURSE INTERVENTION PROTOCOLS FOR SCABIES
44